mother-infant forensic psychiatry: the good, the bad & the ... · mother-infant forensic...
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Mother-Infant Forensic Psychiatry: The Good, the
Bad & the Ugly
Professor Anne Buist
Northpark and Austin Hospitals
University of Melbourne
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Structure of the Seminar
1. Background – stats on child deaths and abuse, risks of mental illness and poor parenting
2. Assessment
3. Examples
4. Giving Expert Evidence
5. The Emotional Cost
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Perinatal Mental Illness
• Risk of serious mental illness increases thirty fold in the month postpartum
• 15% postnatal depression
• 1 in 600 postpartum psychosis
• Over 70% relapse postpartum for bipolar affective disorder (untreated)
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Association of Mental Illness with:
• History of child abuse: intergenerational transmission
• Family history of mental illness
• Poor parenting role models
• Unstable or no partner
• Rape victim/sexually transmitted disease
• Drug Abuse
• Poverty
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Specific Parenting Difficulties can arise in Some Disorders:
• Psychosis: acute risks as well as neglect
• Mood and Anxiety disorders: attachment difficulties, suicide-homicide
• Personality disorders: disorganised attachment, abuse and murder
• Drug and Alcohol: neglect, abuse and murder
• Intellectual Deficit: neglect and abuse
• Autism Spectrum Disorder: attachment difficulties and emotional abuse
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Child HomicidesWorld-Wide
• Homicides under age 15 • 2.58/100,000 in low income countries• 1.21/100,000 in high income countries
• USA : I infant under I year killed every day (Spinelli AMJ 2004)
• Australia ninth lowest• 0.8/100,000
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Child Deaths
• 2.6 per 1000 in high socioeconomic suburbs (where <2% mothers smoke) versus 8-9 per 1000 in Northern NSW and Nth Queensland (33% mothers smoke), 13 per 1000 for Indigenous
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Child DeathsNSW 2014
• 28.41 per 100,000: over represented Indigenous
• 485 total(data for 461)
• 78% natural (mostly first 28 days)
• 17%(80) injury
• 49 unintentional (nb MCA)
• 22 suicide (ages 10-17)
• 9 abuse related
• 4%(20) Undetermined (SIDS)
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Definitions
• Filicide: parent killing a child
• Infanticide: • legal defense in some countries only
• mother killing an infant (usually) under the age of one
• Neonaticide: killing of neonate within 24 hours of birth
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• Highest risk of murder is in the first day of life
• 10% of filicides in first week
• 30% filicides in first year
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Neonaticide
• Strong association with young girls, denial of pregnancy, unassisted deliveries, intermittent amnesia
• Families with role confusion, boundary violations and emotional neglect, chaotic and rigid
• Half with abuse histories
From:M Spinelli 2003
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Neonaticide
METHODS
• Suffocation
• Head Trauma
• Drowning
• Strangulation
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Infanticide beyond the first Day
• Risk Factors:• Second or subsequent children of mothers<19
• Mothers <19 years
• No prenatal care
• Low level education
• Diagnosis???
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Methods of filicide (Resnick 2007)Maternal (90) Paternal(42)
Head trauma 13 28
Strangulation 14 17
Stabbing 9 14
Shooting 9 7
Suffocation 10 5
Thrown from height 10 2
Gas 9 5
Poison 6 5
Assault 0 7
Starvation 3 0
Burning 0 5
Total (132) 100% 100%
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Diagnosis (Resnick 2007)
Schizophrenia 22%
Psychosis (other) 24%
Nonpsychotic 15%
Personality
Disorder
12%
Severe depression 11%
Nil 7%
Bipolar 2%
Intellectually
Disabled
2%
Neurosis 2%
Delirium 2%
Epilepsy 1%
TOTAL 100%
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Abuse in Australian Families
• 1996 - 31,010 reports, 6,798 substantiations, 28,337 active clients 0.67 deaths per active clients (n=19)
• 2010-11 40,466 substantiations (237,273 notifications of which 127,759 investigated)
• 2013-14 54,438 substantiations (304,097 notifications and 137,585 investigations)
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SubstantiatedAbuse by State
State 2009-10 2013-14
NSW 26,248 26,214
VIC 6,603 11,952
QLD 6,922 7,406
WA 652 3,267
SA 1,815 2,737
TAS 963 778
ACT 741 449
NT 1,243 1,634
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Types of Abuse 2013-14
•Emotional 16,093
•Neglect 11,194
•Physical 7,906
• Sexual 5,581
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NOT all mentally ill parents are a risk to their children
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Removals of children from mothers in psychiatric units
•Most common diagnosis schizophrenia, but severity of illness and level of supports the key association
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Characteristics of Child
• Female (double) for sexual, physical increased risk for boys
• Rates decrease with age
• Indigenous seven times more likely
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The trauma: effect on the child
These result in potential long term impact on neurobiology and psychology
• Those that result from antenatal exposure to drugs, alcohol and DV
• The traumas that resulted in a notification (not an issue if removed at birth) eg xposure to DV
• Separation
• Reunification
• Ongoing parental difficulties
• Failed reunification (each time)
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Zero to Three:Who Assesses?
• Family Court psychologists (Family Consultants) and (private) psychiatrists
• Children’s Court psychologists and psychiatrists (some private)
• Forensicare
• Paediatric services
• Mother-Baby Hospitals (eg Queen Elizabeth/Tweddle)
• (Psychiatric) Mother-Baby Units
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• “The area of child custody assessments continues to fail to meet evidence-based threshold”
Byrne et al (J Chil Psychol&Psych 2005)
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Problems
• Legal versus Psychological language
• Varied conceptual basis (psychological theories)
• Little systematic research in dispute/legal/custody setting
• Parental bias in information
• Lack of cross-fertilisation within clinical speciliaties and to law
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Attachment
• Should be assessed (Bernet 2002)
• Critical to the IASA protocol (Crittenden et al ‘13)
• It alone should not be used to make decisions re custody
• Who interprets?
• Different attachment to different parent – while one is primary, these are building blocks rather than either /or (Sroufe 2011)
• Attachment is only part of a parenting assessment
• How predictive is it in custody setting?
• Who owns the video?
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What is “Good Enough” and how much risk is less than the risk of separation?
• No “no” risk scenarios
• When are drugs too dangerous, if mother won’t leave when is “some” DV ok to leave children exposed to?
• Risks also in foster/statecare
• Rights of Child: Attachment needs paramount under age three
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The Conundrum
• Child removed for months (one-two years) and in stable care (that can be ongoing)
• Issues for removal “soft” but multiple-DV exposure, “mental health issues” leading to unreliable care/verbal abuse
• Mother • in no relationship or another unstable one
• Improved but still issues (often borderline IQ as well)
• Only seeing child once a week
• Father• May or may not still be in mix
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Principles of Assessment• Physical Care
• Routine
• Reading cues/Ability to feed/ settle/identify illness
• Ability to protect
• Ability/willingness to access appropriate help
• Anger management
• Emotional Care• Reading cues
• Reflective functioning
• Attachment
• Flexibility
• Boundaries
• Taking charge
• Backup plans/safety
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Context
• Longitudinal History • Own attachment history
• Illness (physical or mental)
• Comorbidity nb drug use
• Personality
• Relationship history
• Supports and Protective Factors
• Intellectual capacity
• Anger management
• Forensic history
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Children’s/Family Court
• Need to manage contradictory information
• Flexible interview process• differing parental accounts
• Multiple data gathering methods• Interviews with parents, family, teachers, doctors, treating
counsellors
• Parent-child observation
• Formulation …multiple hypotheses possible
• Children’s Court broader and a range of experts as needed
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PADSDS10 day residential assessment0-3years
Advantage – in home over time
Disadvantage – mother must be safe enough or have other adult to care for child
• Safety
• Feeding and nutrition, hygiene
• Routines, sleep/settling
• Care of the unwell child
• Developmental needs
• Interactions and mutual responsiveness
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Mother-Baby Hospitals
Advantage- safe and intensive, can have both partners, sometimes an older child
Disadvantage- parent removed from other life stresses and if parent not primary carer, an attachment trauma for the child
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Mother-Baby Units0-12mths, parent with mental illness
• Safety – nb re medication and illness, hospital versus community issues
• Feeding and nutrition
• Routines, sleep/settling – nb flexibility
• Developmental needs – nb flexibility
• Interactions and mutual responsiveness
• Who else can help?• Partners and family• Community supports, child care
• Attempt to provide best plan for baby ongoing care to family and DHS
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Private Psychologists and Psychiatrists• No agreed assessment
practice, includes WAIS, neuropsych assessment, MMPI, and adaptions of AAI, PDI, SSP and COS
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What should an assessment include?
• Experts hired by court who are impartial and able to put child first and able to explain to court the significance of findings in lay terms
• Acceptance of complexity and no one rule fits all
• Use of a number of tools: SSP, Attachment Q-sort, AAI/ reflective functioning (Steele)
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The answer in any case needs to resolve…
• What is the best option for this child at this time to provide them with a primary carer most able to provide an environment where it is not just physically safe but best has its emotional needs met (with or without support)
• Does the relationship with the other parent need to be an attachment one in the earliest years?
• A matrix for decision making?
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Future Direction?
• Dynamic-Maturational Model of Attachment and Adaption (DMM, Crittendon 2016) being used as a basis for a Family Court Protocol to reduce the idiosyncratic nature to proceedings, based on clinicl and neurological underpinnings
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International Association of the Study of Attachment (IASA) Protocol
• High level of expertise using standardised assessment tools
• Assessing whole family
• Neutrality- blind to issues before assessment (then reassess)
• Family Functional Formulation
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What do I do?
• Interview with the parent (1 – ½ hours if alone, 2 – 2 ½ hrs if other parent attending)
• Own early attachment• Five words or phrases (AAI)
• Attachment to Child • Five words or phrases (COSI)
• SSP
• Reflective functioning• Why did your parents behave as they did/ what
effect did it have on you?
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Other options
• Home assessment
• Observation of mother-child in a variety of tasks
• Neonatal behavioural assessment scale
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EXAMPLES
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Denial of Pregnancy
• The Bad: You will only ever see these after the fact
• The Good: But…sometimes the baby survives
• The Ugly: Can lack remorse
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Key aspects to assess
• Were they dissociated at the the time of delivery?
• Maturity nb emotional
• Intellect – problem solving
• If they are to have the baby – supports?
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Keli Lane vs Punishing Karen
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Assessing those that kill
• Try to understand why: Complex motivations that need to be made clear to the court
• More often grey than black and white
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Psychosis/Severe Depression
• The Good:• They often (though not always) present, and can be
quite dramatic
• The Bad:• They can hide/mask their symptoms
• The Ugly• They can kill themselves and their children
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Andrea Yates
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• She was seeing a psychiatrist
• She wasn’t compliant
• The voices were telling her not to tell the psychiatrist about them—and she hated her antipsychotic side effects
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Could the tragedy have been prevented?
• Longer inpatient treatment
• Depo
• Not being left alone with the children
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Abuse
• Good: child is alive
• Bad: child is traumatised and their parent struggled to manage them when “well”
• Ugly: there isn’t time to “reparent” the parent—sometimes there is no good answer
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Abuse – but who did it and is failing to protect enough to stop custody?
• 5 week old infant seen by MCHN who was worried-asked mother to take to GP.
• GP couldn’t see, MCHN rang and insisted she take child to hospital
• Child shown to have two tibial and one ulna fractures
• Father admits he dropped child when caring for 3 days earlier- he maintains and mother supports it was an accident.
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• Mother denies problems in childhood- sister tells of mother violent and alcoholic
• Mother avoidantly attachment, no supports and unable to manage byself
• Child hysterical at access – can be calmed by everyone except the parent
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Giving Expert Evidence
• The Report – clear, concise…and kind• Don’t always believe what you are told…
• You know more than the court about mothers, babies, mental illness and parenting – you need to inform the court
• You don’t decide – the judge does. But they need the best possible information so they do so wisely
• They need a lot of education in some cases…
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The Emotional Cost
• “I’m not looking forward to this court case.”
• “Neither am I. I feel an intense sadness for (mum) and (baby).”
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• Making sense of the parent who doesn’t love their child – understanding and not judging
• “Heart of Gold” : You can’t always recommend reunification even if they love their baby
• Holding the risk – what if you do recommend reunification and they kill their child? • The two psychotic patients who met in the forensic
hospital and then had a child
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Crittenden’s 10 ideas of an integrative approach to treatment:
• Do unto parents as you would have them do to their children
• Accept the complexity of psychological and behavioural problems
• Recognise the crucial importance of attachment relationships in both development and treatment
• Define parenting problems as interpersonal and strategic responses to perceived danger and combine child protection and mental health services to address parenting problems
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continued
• Assess families, formulate the family situation and reassess and reformulate as treatment progresses
• Embrace discrepancy personally – only way for therpaiists to know themselves and safest way to help others
• Deliver services to families through transitional attachment figures who have access to a wide array of therapeutic approaches
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continued
• Embrace discrepancy in treatment as the means to personalise treatment/make more effective
• Combine child, adolescent and adult services as human mental health services
• Fund unlimited family services, use informal community services and limit expenses of out-of-home care (not the reverse)
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Major references
• Byrne et al Journal of Child psychology & psychiatry (2005) 115-127
• McIntosh J Ch 4 More than a Question of Safety. Family Court Review Vol 49(3) July 2011
• Crittenden P. Raising Parents: Attachment, Represenation and Treatment 2015